Brain Fitness
May 2014

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Recent findings about the effectiveness of brain-training software are promising, though not definitive. If use of computer games and other interactive software can lead to improved cognition, students could overcome learning disabilities, adults could boost their multitasking abilities, unemployed people could rapidly retrain for new work, and elderly folk could preserve safe-driving skills and short-term memories. Alternatively, if brain training is mainly a practice of wishful thinking, its market could resemble the large market for weight-loss gimmicks.

Brain-training software aims to use today's neuroscience to improve and protect cognitive abilities by engaging the brain's neuroplasticity—that is, by modifying the interconnections and signaling mechanisms among neurons in the brain. In a January 2014 report, analysis firm SharpBrains indicated that during 2013, suppliers collected worldwide revenues of some $1.3 billion for brain-training and cognitive-assessment technologies. A previous report the company issued during December 2012 estimated the worldwide market would reach $1 billion that year, implying a current annual growth rate of some 30%. The 2012 report forecasted that revenues in 2020 could be in the $4 billion to $10 billion range, "with $6 billion being the most likely scenario." Nintendo raised awareness of the brain-fitness-software product category with the 2005 release of two games in its Brain Age series, both of which remain among the top ten all-time best-selling games for the company's handheld DS platform. Since then, other developers appear to have surpassed Nintendo's market share—notably Lumos Labs and Posit Science. Another vendor, Vivity Labs, was acquired recently by language-learning-software specialist Rosetta Stone.

Users are motivated to gain a competitive edge at work and school and, if possible, to protect themselves against Alzheimer's disease. But no evidence indicates that any type of intervention prevents or cures Alzheimer's disease and other afflictions that have similar outcomes. In general, the goal of brain-training software is not to improve a person's performance at a specific cognitive task but to improve a person's ability to handle unforeseen tasks. Can people who improve their scores in brain games also improve their cognitive abilities for use outside the game?

Evidence and Impacts on Memory

A metastudy published in the February 2013 edition of Developmental Psychology reviewed more than 20 previous controlled studies and found that most well-designed studies of software interventions aimed at boosting memory indicate that brain training has no benefit or only small effects. But in September 2013, a team led by University of California, San Francisco, researchers published unusually favorable results in Nature, the cover of which heralded the study with the words GAME CHANGER in large print. Users who played a custom-designed multitasking-while-driving game, NeuroRacer, scored substantially higher on measures of memory and attention, even several months after they stopped playing, than did a control group of research subjects who never played the game. The study's lead author, Adam Gazzaley, intends to commercialize the technology underlying NeuroRacer, and he is one of the cofounders of start-up Akili Interactive Labs.

NeuroRacer might influence other designers of commercial brain-training games to implement similar sustained-multitasking challenges. And NeuroRacer may have already influenced government policy. During February 2014, the US government's Centers for Medicare and Medicaid Services notified insurers that it will reimburse costs of certain "memory fitness activities" starting in 2015. The activities must be part of "a broader health education benefit" and not a "stand-alone" activity; apparently, officials want patients to enjoy possible advantages of memory training but are cautious about spending on services whose value remains unproved.

Cognition, Vision, and Safe Driving

Can neuroplasticity and brain training help people older than age 65 sustain safe-driving abilities? During 2011, researchers showed that a group of 127 drivers older than age 65 who trained with visual-cognition software had reduced likelihood of being in a collision during the six-year period following the training, as indicated by state motor-vehicle records. The drivers were among the 2000 research subjects of the largest scientific investigation of brain training to date, which spanned ten years and was funded in part by the US National Institutes of Health. Another study demonstrated that similar training reduced stopping distance in driving simulators.

Significantly, in 2008, Posit Science, which has called itself "the leading provider of clinically proven brain fitness programs," acquired Visual Awareness Research Group Inc., whose software was by that date deeply integrated into the protocols of the ten-year study and was the basis for the motor-vehicle-collision study. The software presents a visual representation of a scene and introduces distractions that the user learns to ignore while responding to the software. Visual Awareness has published evidence in support of the idea that brain games can help people improve their abilities to process visual information and restore "useful field of view" that may otherwise erode with age. Posit Science now sells Drivesharp, a vision-training-and-assessment module that is similar to the software the study used and is based on the technology Visual Awareness championed.

Some insurers have embraced the software in diverse but limited ways. State Farm discounts insurance for Alabama customers who pass an assessment that Posit Science supplies. AAA Southern New England donated $1 million in Drivesharp software licenses to libraries. Customers of The Hartford enjoy discounts on Drivesharp purchases. And Allstate has trialed Drivesharp with a group of drivers in Pennsylvania and may be waiting to see if long-term driving-safety outcomes are favorable. Significantly, because the lead author of the ten-year study, outstanding researcher Karlene Ball, is also an inventor of the technology underlying Drivesharp and owns stock in Posit Science, independent scientific verification is likely essential for increased acceptance of the extraordinary idea that use of software can make driving safer.

Better Vision through Neuroplasticity

In another insurance-related development for healthy vision, during March 2014, German insurer Barmer GEK announced that it will provide reimbursements for the cost of using Caterna Vision's cloud-based software for treating amblyopia (lazy eye), a relatively common disorder of binocular vision. For both adults and children, computer-based brain-training therapy for disorders of binocular vision sees some use, though it is not the prevailing treatment. Some studies indicate computer-based vision therapy has limited efficacy. But motivated patients may benefit.

What about more common forms of vision impairment such as nearsightedness and farsightedness? Eye doctors typically believe that previous generations of self-directed eye exercises have placebo-like effects. But a niche of ophthalmologists supervise patient use of perceptual-learning software, which aims to use current findings in neuroscience to teach the brain to improve how it uses the eyes. Could computer software and mobile apps reduce need for common corrective eyewear by improving visual acuity as measured with common eye charts? Evidence is tantalizing and may even be solidifying, but it still lacks thorough independent review. Most of the relevant studies were led by persons associated with developer RevitalVision, which claims that during recent years it has helped "thousands of customers" to see better. The company's software is available only from doctors and is for patients who are farsighted or are recovering from eye surgery. But during recent months, two additional start-up developers have publicly released perceptual-learning computer software and mobile apps that train users and assess vision.

Carrot Neurotechnology released perceptual-learning software for the iPad and Macintosh and Windows PCs during January 2014. The 17 February 2014 edition of Current Biology published results of a study whose authors include principals of the company and whose funders included the US National Science Foundation and National Institutes of Health. The authors assert that brain-trained members of the University of California, Riverside, baseball team saw improvements in visual acuity and batting statistics that their untrained teammates (the control group) did not—and that the team's 2013 win-loss record reflects that improvement.

During December 2013, GlassesOff released an app for the iPhone and iPad that uses technology the company licensed from RevitalVision. The US National Institutes of Health and GlassesOff contributed to funding a study whose results were published online by the peer-reviewed journal Scientific Reports during February 2012. Research subjects ages 47 to 55 who followed a perceptual-learning protocol reportedly saw improvements in visual acuity and reading speed. The middle-aged subjects were experiencing the age-related vision impairment presbyopia—a form of farsightedness that has no known cure and reportedly affects more than 1 billion people worldwide, including more than half of adults older than age 30 and nearly everyone older than age 65.

Brain-Training Caveats

Brain-training benefits are still uncertain. Research and business-development "noise" is almost deafening. Although tantalizing signs indicate potential breakthroughs in visual perception, investigators have so far produced only limited evidence of improvements in memory, attention, and quality of life. Yet news headlines exaggerate the benefits of brain training. A minor scandal erupted in the United Kingdom when schools made unwarranted purchases of an inadequately screened training program. The ten-year study of 2000 people older than age 65 that I mention above had some positive findings; however, on average, trained users saw no significant memory improvements and at the conclusion of the study were no more able to function independently than their untrained peers. And the metastudy I mention above excluded scores of additional previous studies for poor quality and bias. Conflicts of interest are pervasive even in otherwise well-designed studies of brain training's effects. Independent verification, the hallmark of science, is in short supply. Repeated experiments are all too rare. Many protocols seem to "teach to the test" instead of verifying that new skills are transferrable to the real world.

But markets can grow quickly even if brain training is ineffective. Hopes for improved cognition, like hopes for a slim and attractive body, might overcome good judgment. As with today's market for weight-loss helpers—which is several times larger than the brain-training market will be in 2020 according to SharpBrains' most optimistic forecast—the brain-training market will perhaps see tens of billions of dollars per year of revenue for solutions of dubious value.

Concluding Perspectives

Despite the caveats, the problems that brain-fitness developers are trying to solve are important. Results of the NeuroRacer study and the ten-year study include sobering data that correlate increasing age with decreased measures of cognition. Perhaps every person is weak in some attribute of cognition, and perhaps most people will face cognitive challenges at some point after age 65. In an environment that sees billions of dollars invested in social media, a few million for furthering brain fitness is not excessive.

Big data may be supplanting big science in jurying brain training. Leading brain-training-software suppliers already gain new knowledge by using cloud resources to assess users. Such economical crowdsourcing efforts might be an important feedback loop to help research funders select candidate technologies for costly controlled studies. Even without huge databases, wise application of data science may be transformative for an organization, as in the case of Carrot Neurotechnology's effort to link brain training with one baseball team's improved statistics. Truly big crowdsourced neuroscience databases will likely cross people's privacy boundaries to a greater or lesser extent. Even so, another big-data concept, personalized medicine, might see a big payoff by reapplying brain-training companies' computerized assessment capabilities to quantify cognitive benefits of nutrition, drugs, and other types of interventions.

Near-term and midterm markets may see a boost from effective application-specific solutions. Personal goals such as becoming a better baseball player and societal goals such as reducing motor-vehicle collisions could make narrow goal-oriented styles of brain training commonplace. But the foundations of brain training are still under construction. If confirmed, the type of memory breakthrough that NeuroRacer seems to promise could have large and widespread effects on everyday life, business rules, and regulations. A wide range of benefits and impacts could arise if brain training can improve other basic aspects of perception and cognition such as visual acuity and vigilance. And if neuroplasticity can protect vision, perhaps it can protect against hearing loss. On the continuum of transferable skills that are nearer to and more distant from the specific limited tasks that brains undergo in training, some of the most ambitious far-transfer goals include general improvements in speed of learning, attentiveness, and concentration. Brain training that addresses such general needs may help overcome learning disabilities and preserve the ability of the elderly to live independently.

Even so, the greatest market potential arises if brain training advances human potential, not just remedies for disorders and protections against deterioration. Big data and crowdsourcing might reveal that training can boost baseline measures of productivity and creativity. In an ideal case, the field's seeming current emphases on improving performance at multitasking and cognition in the presence of distractions could see a shift. Best-case outcomes of brain training might foster a high quality of life that reduces need for multitasking and imposes less distraction.

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